This worksheet may be printed and used to begin

US Graduates
Program Name:
A University of Wisconsin Hospital and Clinics sponsored GME program
Application Deadline:
Thank you for your interest in Graduate Medical Education at the University of Wisconsin Hospital and
Clinics. Here is checklist of items needed for your application to be considered complete. For students
and graduates of non-LCME accredited medical schools (IMGs) please see the reverse side.
UWHC Uniform Graduate Medical Education Application form for non-ERAS applicants
(completely filled out and signed. CVs will not be accepted in lieu of the Application). You must sign
and date the attestation form at the end of the application.
Current and former Program Director(s) letter of recommendation (original letters, copies will not
be accepted. All former Program directors must be included) An email or documented phone call
between program directors is acceptable in lieu of requirement.
USMLE scores or NBOME (COMLEX scores). If we can verify full medical licensure that required
Step III completion via the AMA profile, this requirement will be waived.
Other letters of recommendation (minimum of 2—our program requires
accepted.)
Copies will be
Medical School Transcript. If we can verify your graduation via the AMA profile, this requirement
will be waived.
Medical School Letter of Evaluation (formerly known as the Dean’s letter). Copies will be accepted.
Personal Statement. Please write a current one for this application.
Please return all materials to:
Program Name
Address
Attention:
UWHC Uniform Graduate Medical Education Application – September 2010 (for non-ERAS applicants)
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International Medical Graduates
Program Name:
A University of Wisconsin Hospital and Clinics sponsored GME program
Application Deadline:
Thank you for your interest in Graduate Medical Education at the University of Wisconsin Hospital and
Clinics. Here is checklist of items needed for your application to be considered complete. (For
students and graduates of LCME accredited medical schools (US Graduates) please see the reverse
page.
UWHC Uniform Graduate Medical Education Application form for non-ERAS applicants
(completely filled out and signed. CVs will not be accepted in lieu of the Application). You must sign
and date the attestation form at the end of the application.
ECFMG certificate (must be complete prior to start of training).
Current and former Program Director(s) letter of recommendation (original letters, copies will not
be accepted. All former Program directors must be included) IMG’s must have at least one letter from
a program director certifying one year of US clinical experience.
USMLE scores or NBOME (COMLEX scores) ECFMG is OK.
Other letters of recommendation (minimum of 2—our program requires
accepted.)
Copies will be
Medical School Transcript (from ECFMG)
Medical School Letter of Evaluation (if available, in English) Copies will be accepted.
Personal Statement. Please write a current one for this application.
Please return all materials to:
Program Name
Address
Attention:
UWHC Uniform Graduate Medical Education Application – September 2010 (for non-ERAS applicants)
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University of Wisconsin
Request for Letter of Recommendation
For Non-ERAS Application Process
Date:
Letter Writer:
Applicant Name:
Thank you for agreeing to write a letter of recommendation in support of my application. This
sheet explains the special procedures needed to prepare a letter for the University of
Wisconsin Hospital and Clinics residency programs.
Please send the letter of recommendation to the designated department using the following
format. Letters from Program directors must be signed originals.
Letters from faculty other than Program directors may be a copy.
1. Address the letter to “Dear Program Director or Department Chair”.
(I would be happy to provide you a list of programs to which I am applying). Include
in the letter that I have or have not waived my right to see this recommendation, as
indicated below.
2. Write your letter on letterhead.
3. Please print your letter to be placed in my file.
4. Attach this sheet to your letter before sending it, to help my designated department
to identify your letter with my file.
Thank you in supporting my application.
_____ (I waive) _______ (I do not waive) my right to see this letter. If “waived” is checked, I
waive my right to see this letter. I acknowledge that this letter is for the specific purpose of
supporting my application for an Internship, Residency or Fellowship.
SIGNED: _____________________________________________________
Mailing Address:
Name:
Department:
Address:
City:
Phone:
Email:
__________________________________________________
__________________________________________________
__________________________________________________
__________________ ST: _____________ ZIP: ___________
__________________________________________________
__________________________________________________
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UWHC Graduate Medical Education Application
(for non-ERAS applicants)
This worksheet may be printed and used to begin completing your application non-electronically. If you wish to submit a nonelectronic copy it must be typed or completely legible. All required fields are marked with an asterisk (*). Please note,
however, that some of these fields are required only in certain circumstances. For example, if you state that you did earn or
expect to receive a degree from an institution, you will be required to enter what that degree is.
(PLEASE PRINT OR TYPE WHEN FILLING OUT THE APPLICATION).
Program Applying For: ___________________________
Program Start Date: ___________
Anticipated Training Year: ______________
Profile
First Name: ____________________________ *
Middle Name: ___________________
Last Name: ____________________________*
Suffix: ________________
Degree:
MD
Previous Last Name: _______________________________
MD, PhD
DO
MBBS
MBchS
Current Address:
Street Address: _________________________________________________________________ *
City: _____________________________
Post Code:_________________*
* State/Province: _______________________ *
Country: ____________________________ *
Preferred Phone:_(______)____________________ * Alternate Phone:_(______)_____________ *
Mobile: _(______)____________________
Fax: (______)________________
Pager: _(____)_____________________
Contact Email: _______________________________*
Permanent Mailing Address:
Street Address: _________________________________________________________________ *
City : ______________________________________ *
State/Province: _____________________ * Post Code: __________________ *
Country: __________________________ *
Social Security Number:
SSN: _______________ *
Phone: _(_____)___________________ *
NPI: ________________
Canadian SIN: ________________
Match Participation:
I am applying for position outside the match.
I am participating in the NRMP Main Match.
I am participating in the NRMP Specialties Match.
I am participating in a match as part of a couple AND I wish to notify programs of
this.
San Francisco Matching Service
AUA Number: ______________________________ (required for Urology Match Participants only)
Other ______________________________
Specialties Partner is applying to: __________________________ Partner’s Name: __________________________
UWHC Uniform Graduate Medical Education Application – September 2010 (for non-ERAS applicants)
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Military
Are you committed to fulfill U.S. Military active duty service obligations/deferments? *
No
Yes If Yes: Years: __________ Branch: _________________________
Do you have any other service obligations? (i.e. Military Reserves or Public Health/State programs) *
No
Yes: Description:
___________________________________________________________________________________________________
___________________________________________________________________________________________________
Work Eligibility
Yes
Do you meet one of the following criteria?
No
1. US citizenship
2. Permanent legal residency status in the US (green card)
3. Eligible to hold a J-1 Clinical Visa sponsored by ECFMG.
Note: The UWHC will not sponsor H-1 (temporary worker) visas. Other legal documents authorizing work In
the United States will be reviewed by the GME office.
Foreign Medical Graduates:
Are you certified by the Educational Commission for Foreign Medical Graduates? – (attach a copy of the
ECFMG certificate). Check all that apply.
No
Yes Month: ____________ Year: _______ USMLE/ECFMG ID: ____________
ECFMG certificate is attached with the application * (Label as 2-a)
Miscellaneous
Foreign Medical Graduates applying for Residency Positions: To be answered by Foreign Medical Graduates
only. See www.ecfmg.org/eras for information and mailing instructions.
Yes
No
Will you provide a MSPE to the UWHC? *
Will you or your medical school provide a transcript to UWHC? *
**Please attach copies and a translation if not in English
Yes
No
Non-Medical Education
For each non-medical educational institution you have attended, please provide the requested information. You may create
as many entries as needed on the electronic form or add an additional page.
None
#1 Institution: ____________________________________________________________________________*
Location: ________________________________________________________________________________*
Education Type: *
Undergraduate
Graduate
Other
Major:___________________________________________________________________________________*
Degree expected or earned: *
Yes
No
Degree: _______________________________
Degree Month: ___________
Degree Year: _________
Dates of Attendance: From _________________ To _________________ *
(Month/Year)
(Month/Year)
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#2 Institution: _____________________________________________________________________________*
Location: ________________________________________________________________________________*
Education Type: *
Undergraduate
Graduate
Other
Major:___________________________________________________________________________________*
Degree expected or earned: *
Yes
No
Degree: _______________________________
Degree Month: ___________
Degree Year: _________
Dates of Attendance: From _________________ To _________________ *
(Month/Year)
(Month/Year)
Refer to attachment for additional information. (Reference as 3-a, 3-b etc.)
Medical Education
For each medical school you have attended, please provide the requested information. You may create as many entries as
needed on an additional page.
#1
Country: ________________________________________________________ *
Institution: _______________________________________________________*
Clinical Campus:__________________________________________________ *
* only available for select US Medical Schools
Degree expected or earned: *
Yes
No Degree: ___________________________________
Degree Month: ___________ Degree Year: ________ *
Dates of Attendance: From ___________________ To ___________________ *
(Month/Year)
(Month/Year)
#2
Country: ________________________________________________________ *
Institution: _______________________________________________________*
Clinical Campus:__________________________________________________ *
* only available for select US Medical Schools
Degree expected or earned: *
Yes
No Degree: ______________________________________
Degree Month: ___________ Degree Year: ________ *
Dates of Attendance: From ___________________ To ___________________ *
(Month/Year)
(Month/Year)
Refer to attachment for additional information. (Reference as 3-c)
Previous Residency/Fellowship Training
For each internship, residency, or fellowship position you have held or currently are in, regardless of the amount of time
spent there, please provide the requested information. This worksheet has space for you to make 3 entries. You may create
as many entries as needed on an additional page.
None
#1
Specialty: _________________________________________________________ *
Type of Training:
Internship
Residency
Fellowship *
To:
From:
Month/year
Month/year
Institution/Program:______________________________________________________________*
Dates of Residency/Fellowship:
City:__________________________* State/Province: _________________ * Country: ____________________ *
Program Director:______________________________ *
Supervisor:_________________________________ *
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#2
Specialty: _________________________________________________________ *
Type of Training:
Internship
Residency
Fellowship *
Dates of Residency/Fellowship:
From:
To:
Month/year
Month/year
Institution/Program:______________________________________________________________*
City:__________________________* State/Province: _________________ * Country: ____________________ *
Program Director:______________________________ *
Supervisor:_________________________________
#3
Specialty: _________________________________________________________ *
Type of Training:
Internship
Residency
Fellowship *
Dates of Residency/Fellowship:
From:
To:
Month/year
Month/year
Institution/Program:______________________________________________________________*
City:__________________________* State/Province: _________________ * Country: ____________________ *
Program Director:______________________________ *
Supervisor:_________________________________
Chief Resident (only relevant for Fellowship Applicants)
Dates of Attendance Residency/Fellowship:
From _____________ To ______________
(Month/Year)
(Month/Year)
Reason for Leaving: ______________________________________________________________________________
_______________________________________________________________________________________________
Was your medical education/training extended or interrupted? Please explain any gaps of 3 or more months during your
medical education and /or residency training. *
No
No Response
Yes Reason: ___________________________________________________________
______________________________________________________________________________________________
Refer to attachment for additional information. (Reference as 4-a)
State Licenses
For each state license you have, please provide the requested information. This worksheet has space for you to make 2
entries.
None
#1
State: ___________________ * License Type:
Full
Temporary or Limited
Inactive
License Number:________________* Expiration Month__________* Expiration Year ________*
(License number, expiration month and expiration year is only required if license type is “Full”)
#2
State: ___________________ * License Type:
Full
Temporary or Limited
Inactive
License Number:________________* Expiration Month__________* Expiration Year ________*
(License number, expiration month and expiration year is only required if license type is “Full”)
Refer to attachment for additional licenses. (Reference as 4-b)
Medical Licensure
Has your medical license ever been suspended/revoked/voluntarily terminated?
No
Yes Reason: _________________________________________________________________________
_____________________________________________________________________________________________
_____________________________________________________________________________________________
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Have you ever been named in a malpractice case? *
No
Yes Reason: Reason:
______________________________________________________________________________________________
______________________________________________________________________________________________
______________________________________________________________________________________________
Malpractice Claims History is attached (Reference as 5-a)
Is there anything in your past history that would limit your ability to be licensed or to receive hospital privileges? *
No
Yes Reason __________________________________________________________________________
_____________________________________________________________________________________________
_____________________________________________________________________________________________
Have you ever been convicted of a felony? *
No
Yes Reason: _________________________________________________________________________
_____________________________________________________________________________________________
_____________________________________________________________________________________________
Are you Board Certified?
Yes
No
1.
Board Name _________________________
Expiration: _______
2.
Board Name _________________________
Expiration: _______
3.
Board Name _________________________
Expiration: _______
DEA Registration:
Number _______________________________ * if applicable
Expiration Month: __________ Expiration Year: _________________
Examinations
For each examination you have taken, please provide the requested information. This worksheet has space for you to make
4 entries. (Osteopathic applicants: include the exams (COMLEX or USMLE) that lead to the medical licensure route you
intend to pursue).
None
Exam #1:
1st attempt
2nd attempt
USMLE Step I
USMLE Step II CK
USMLE Step II CS
USMLE Step III
COMLEX Level I
COMLEX Level II
COMLEX Level III
Exam #2:
1st attempt
2nd attempt
USMLE Step I
USMLE Step II CK
USMLE Step II CS
USMLE Step III
COMLEX Level I
COMLEX Level II
COMLEX Level III
Passed
Passed
Failed
Failed
NBME I
NBME II
NBME III
Passed
Passed
Failed
Failed
NBME I
NBME II
NBME III
Month: _____________ * Year: ________ *
Month: _____________ * Year: ________ *
Awaiting results from ____________
Will take on_______________
Incomplete
Month: _____________ * Year: ________ *
Month: _____________ * Year: ________ *
Awaiting results from ____________
Will take on_______________
Incomplete
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Exam #3:
1st attempt
2nd attempt
USMLE Step I
USMLE Step II CK
USMLE Step II CS
USMLE Step III
COMLEX Level I
COMLEX Level II
COMLEX Level III
Exam #4:
1st attempt
2nd attempt
USMLE Step I
USMLE Step II CK
USMLE Step II CS
USMLE Step III
COMLEX Level I
COMLEX Level II
COMLEX Level III
Passed
Passed
Failed
Failed
NBME I
NBME II
NBME III
Passed
Passed
Failed
Failed
NBME I
NBME II
NBME III
Month: _____________ * Year: ________ *
Month: _____________ * Year: ________ *
Awaiting results from ____________
Will take on_______________
Incomplete
Month: _____________ * Year: ________ *
Month: _____________ * Year: ________ *
Awaiting results from ____________
Will take on_______________
Incomplete
Cardiopulmonary Resuscitation & Other Life Saving Intervention Certification
I am CPR / BLS (Cardiopulmonary Resuscitation) certified in the U.S.A
Expiration Date: _______________
(Month/year)
I am ACLS (Advanced Cardiac Life Support) certified in the U.S.A.
Expiration Date: _______________
(Month/year)
I am PALS (Pediatric Advanced Life Support) certified in the U.S.A.
Expiration Date: _______________
(Month/year)
I am ATLS (Advanced Trauma Life Support) certified in the U.S.A.
Expiration Date: _______________
(Month/year)
Experience(s)
For each non-residency relevant work, research, and volunteer experience/position you have had, please provide the
requested information. Include non-residency clinical and teaching experience as work experiences, and include all unpaid
extra-curricular activities and committees you have served on as volunteer experiences. This worksheet has space for you to
make 2 entries. You may create as many entries as needed on an additional page.
None
#1
Type:
Work
Research
Volunteer
Organization:____________________________________________________________________________ *
Position:________________________________________________________________________________ *
Supervisor:__________________________ * Average Hours Per Week:_________
Dates of Experience: From _________________ To ________________ *
(Month/Year)
(Month/Year)
Description:_________________________________________________________________________________________
___________________________________________________________________________________________________
Reason for leaving:__________________________________________________________
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#2
Type:
Work
Research
Volunteer
Organization:____________________________________________________________________________ *
Position:________________________________________________________________________________ *
Supervisor:__________________________ * Average Hours Per Week:_________
Dates of Experience: From _________________ To ________________ *
(Month/Year)
(Month/Year)
Description:_________________________________________________________________________________________
___________________________________________________________________________________________________
Reason for leaving:__________________________________________________________
Refer to attachment for additional information. (Reference as 7-a)
Publications
(Use also for Poster Sessions/Abstracts/Invited National or Regional Presentations) For each publication/presentation you
have had, please provide the requested information. This worksheet has space for you to make 3 entries. You may create as
many entries as needed on an additional page.
None
#1
Title: _____________________________________________________________________________________________ *
_________________________________________________________________________________________________
Authors/Presenters: _________________________________________________________________________________ *
Publication/Organization: _____________________________________________________________________________ *
Month: __________
Year: ________ Volume: __________
Pages: __________
#2
Title: _____________________________________________________________________________________________ *
_________________________________________________________________________________________________
Authors/Presenters: _________________________________________________________________________________ *
Publication/Organization: _____________________________________________________________________________ *
Month: __________
Year: ________ Volume: __________
Pages: __________
#3
Title: _____________________________________________________________________________________________ *
_________________________________________________________________________________________________
Authors/Presenters: _________________________________________________________________________________ *
Publication/Organization: _____________________________________________________________________________ *
Month: __________
Year: ________ Volume: __________
Pages: __________
Refer to attachment for additional publications. (Reference as 7-b)
All applicants:
Language Fluency (Other than English): _________________________________________________________________
_________________________________________________________________________________________________
Hobbies and Interests: _______________________________________________________________________________
_________________________________________________________________________________________________
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Medical School Awards: _______________________________________________________________________________
___________________________________________________________________________________________________
___________________________________________________________________________________________________
Other Accomplishments:_______________________________________________________________________________
___________________________________________________________________________________________________
___________________________________________________________________________________________________
Membership in Honorary/Professional Societies: ___________________________________________________________
___________________________________________________________________________________________________
___________________________________________________________________________________________________
Are you able to carry out the responsibilities of a resident in the specialties and at the specific training program to which you
are applying including the functional requirements, cognitive requirements, interpersonal and communication requirements,
and attendance requirements with or without reasonable accommodations? *
Yes
No Response
No, Limiting Aspects (please explain)
___________________________________________________________________________________________________
___________________________________________________________________________________________________
Attestation
Background Disclosure and Check. I understand that I must fill out a Wisconsin Background Information Disclosure (BID)
form and that a background check will be performed as required by state law. The BID form is considered part of this
application. I understand that I will not be employed or will be removed from employment if the employer discovers certain
crimes or offenses. If I am assigned to work at another site that requires a BID form and check, I authorize UWHC to release
this information to the other site.
Health Screening and Drug Testing. I understand that any offer of employment is contingent on successful completion of a
pre-employment physical which will include mandatory pre-employment drug testing and which also may include alcohol
testing. I understand the UWHC will rescind my offer of employment if I do not comply with all procedures for preemployment drug testing. I understand that I should consider whether I wish to provide notice of my intent to end my
employment with my current employer prior to successfully passing the UWHC’s pre-employment drug testing.
Identity and Work Authorization: Federal law requires UWHC to verify the identity and work authorization of each
successful candidate. Any offer of employment is contingent upon this verification.
Social Security Number: I understand that UWHC will use the Social Security Administration’s Verification Service (EVS) to
verify my social security number after hire, if I am hired.
Authorization of Release of Information. I authorize the release of information to UWHC regarding my work history,
education, licensing/certification and performance. I understand that any offer of employment is contingent upon UWHC
obtaining satisfactory responses to inquires and hold harmless the companies, schools and persons from liability.
Certification of Accuracy and Completeness. I certify that all of the information provided in this application is true and
complete to the best of my knowledge. I acknowledge that I may be required to verify information prior to appointment and
that any omitted, false or misleading information may disqualify me from employment consideration and may be grounds for
termination from employment.
Signed:_____________________________________ Date:_______________
Printed Name:_____________________
Please print off this page. Sign, date, and scan or fax back to program applying for.
UWHC Uniform Graduate Medical Education Application – September 2010 (for non-ERAS applicants)
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Additional Required Questions
Applicant Name: _________________________
Program Name: _________________________
This sheet will be removed before decision makers decide who to interview.
Information below may be discussed during the interview.
Felony Question:
Have you ever been convicted of a felony?
Yes
No
** Section 111.321, Wis. Stats., generally prohibits employment discrimination on the basis of arrest or
conviction record. An employer may only refuse to hire a qualified applicant because of a conviction record for
an offense that is substantially related to the circumstances of a particular job. The legislature has determined
that certain convictions are substantially related to employment in child and adult care giving programs
regulated by the Department of Health and Family Services.
Work Eligibility: *
Which of the following criteria do you meet?
US Citizen
Permanent Resident
Eligible to hold a J-1 Clinical Visa sponsored by ECFMG
Other legal documents authorizing work in the US.
Note: The UWHC will not sponsor H-1 (temporary worker) visas. Other legal documents
authorizing work In the United States will be reviewed by the GME office.
Additional Comments:
______________________________________________________________________________
______________________________________________________________________________
Current Visa Type:
B-1 - Temporary visitor for business
B-2 - Temporary visitor for pleasure
F-1 - Academic student
F-2 - Spouse or child of F-1
TN - NAFTA trade visa for Canadians and Mexicans
H-1 - Temporary worker
TN - NAFTA trade visa for Canadians and Mexicans
H-1B - Specialty occupation, DoD worker, etc.
Diplomatic Service
H-2B - Temporary worker- skilled and unskilled
Immigrant
H-4 - Spouse or child of H-1, H-2, H-3
EAD-Employment Authorization
J-1 - Visa for exchange visitor
Expiration date: _______________ *
J-2 - Spouse or child of J-1
O-1 - Extraordinary ability in sciences, arts, education, business, or athletics
Other
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Information below will only be used after you have been offered a position in order to
complete the hiring process. This information will not be viewed during the interview
process.
Marital Status:
Gender:
Female
Married
Single
Male
Birth:
Birth Date:_________________________ *
Birth Country: __________________________
Birth City: _________________________
Birth State: ___________________________
Racial and Ethnic Group:
This section allows entries for race self-identification. You may select one or more races. Specify "other" if your
race is not listed. You may create as many entries as needed.
Black (not of Hispanic Origin): All persons having origins from any of the black racial groups.
Asian or Pacific Islanders: All persons having origins from any of the original peoples of the Far East,
Southeast Asia, the Indian subcontinent or the Pacific Islands. This area includes, for example, China, Japan,
Korea, the Philippine Islands, Samoa, and India.
American Indian or Alaskan Native: All persons having origins of the original peoples of North America,
and who maintain cultural identification through tribal affiliation or community recognition.
Hispanic: All persons from Mexican, Puerto Rican, Cuban, Central or South American, Iberian Peninsula, or
other Spanish culture or Origin, regardless of race.
White (not of Hispanic Origin): All persons having origins from any of the original peoples of Europe, North
Africa, and the Middle East.
Unknown
Other: _________________________________________________
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